EDI 278 X217 - Health Care Services Review Information - Response

Functional Group HI

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review. Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.

Heading

1. 0100 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

   This segment indicates the start of a health care services review information response transaction set with all the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management response.

2. 0200 · BHT · Beginning of Hierarchical Transaction · Max 1 · Mandatory

   To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

Detail

1. 2000A Loop Mandatory Repeat 1

   1. 0100 · HL · Utilization Management Organization (UMO) Level · Max 1 · Mandatory

      To identify dependencies among and the content of hierarchically related groups of data segments

      This segment indicates the information source hierarchical level. The information source corresponds to the payer, HMO, or other utilization management organization that is the source of the health care services review decision/response.

   2. 0300 · AAA · Request Validation · Max 9 · Optional

      To specify the validity of the request and indicate follow-up action authorized

      Required when the request cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send.

   3. 2010A Loop Mandatory Repeat 1

      1. 1700 · NM1 · Utilization Management Organization (UMO) Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         This segment identifies the source of information. In the case of a response to a request transaction, the information source would normally be the payer or utilization review organization who is the source of the decision regarding the request.

      2. 2200 · PER · Utilization Management Organization (UMO) Contact Information · Max 1 · Optional

         To identify a person or office to whom administrative communications should be directed

         Use this segment to identify a contact name and/or communications number for the UMO.
         Required when the requester must direct requests for follow-up to a specific UMO contact, email, facsimile, or telephone. If not required by this implementation guide, do not send.
         When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.

      3. 2300 · AAA · Utilization Management Organization (UMO) Request Validation · Max 9 · Optional

         To specify the validity of the request and indicate follow-up action authorized

         Required when the request cannot be processed at the system or application level based on the Utilization Management Organization (information source) identified in Loop 2010A. If not required by this implementation guide, do not send.

   4. 2000B Loop Optional Repeat 1

      1. 0100 · HL · Requester Level · Max 1 · Mandatory

         To identify dependencies among and the content of hierarchically related groups of data segments

         Required when the UMO system processed any of the information contained in Loop 2000B. If not required by this implementation guide, do not send.
         If the UMO system was unable to process any data beyond Loop 2000A, Loop 2000B is not used.
         This segment indicates the health care services review information receiver. For responses to request transactions, this segment corresponds to the identification of the provider who initiated the request for review.

      2. 2010B Loop Mandatory Repeat 2

         1. 1700 · NM1 · Requester Name · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

            This loop identifies the receiver of information. In the case of a response to a request transaction, the receiver would normally be the provider who is receiving the decision.

         2. 1800 · REF · Requester Supplemental Identification · Max 8 · Optional

            To specify identifying information

            Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.

         3. 2300 · AAA · Requester Request Validation · Max 9 · Optional

            To specify the validity of the request and indicate follow-up action authorized

            Use this segment to convey rejection information regarding the entity that initiated a request transaction.
            Required when the request is not valid at this level. If not required by this implementation guide, do not send.

         4. 2400 · PRV · Requester Provider Information · Max 1 · Optional

            To specify the identifying characteristics of a provider

            Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.

      3. 2000C Loop Optional Repeat 1

         1. 0100 · HL · Subscriber Level · Max 1 · Mandatory

            To identify dependencies among and the content of hierarchically related groups of data segments

            Required when the UMO system processed any of the information contained in Loop 2000C of the request. If not required by this implementation guide, do not send.
            If the UMO system was unable to process any data beyond Loop 2000B of the request, Loop 2000C is not required.
            This segment corresponds to the identification of the subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient, the dependent hierarchical level (Loop 2000D) is not used.

         2. 2010C Loop Mandatory Repeat 1

            1. 1700 · NM1 · Subscriber Name · Max 1 · Mandatory

               To supply the full name of an individual or organizational entity

               This segment identifies the subscriber.

            2. 1800 · REF · Subscriber Supplemental Identification · Max 9 · Optional

               To specify identifying information

               Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number are to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
               Required when used by the UMO to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the request. If not required by this implementation guide, do not send.

            3. 2000 · N3 · Subscriber Mailing Address · Max 1 · Optional

               To specify the location of the named party

               Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

            4. 2100 · N4 · Subscriber City, State, ZIP Code · Max 1 · Optional

               To specify the geographic place of the named party

               Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

            5. 2300 · AAA · Subscriber Request Validation · Max 9 · Optional

               To specify the validity of the request and indicate follow-up action authorized

               Required when the request is not valid at this level. If not required by this implementation guide, do not send.

            6. 2500 · DMG · Subscriber Demographic Information · Max 1 · Optional

               To supply demographic information

               Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.

            7. 2600 · INS · Subscriber Relationship · Max 1 · Optional

               To provide benefit information on insured entities

               Required when used by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.

         3. 2000D Loop Optional Repeat 1

            1. 0100 · HL · Dependent Level · Max 1 · Mandatory

               To identify dependencies among and the content of hierarchically related groups of data segments

               Required when the UMO system processed any of the information contained in Loop 2000D of the request. If not required by this implementation guide, do not send.
               If the UMO system was unable to process any data beyond Loop 2000C of the request, Loop 2000D is not required.

            2. 2010D Loop Mandatory Repeat 1

               1. 1700 · NM1 · Dependent Name · Max 1 · Mandatory

                  To supply the full name of an individual or organizational entity

                  This segment conveys the name of the dependent who is the patient.
                  NM108 and NM109 are situational on the response but Not Used on the request. This enables the UMO to return a unique member ID for the dependent that was not known to the requester at the time of the request. When the dependent has a unique member ID, Loop 2000D is not used.

               2. 1800 · REF · Dependent Supplemental Identification · Max 3 · Optional

                  To specify identifying information

                  Required when used by the UMO to identify the Dependent or when REF01 = "EJ" (Patient Account Number) is valued on the request. If not required by this implementation guide, do not send.

               3. 2000 · N3 · Dependent Address · Max 1 · Optional

                  To specify the location of the named party

                  Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

               4. 2100 · N4 · Dependent City, State, ZIP Code · Max 1 · Optional

                  To specify the geographic place of the named party

                  Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

               5. 2300 · AAA · Dependent Request Validation · Max 9 · Optional

                  To specify the validity of the request and indicate follow-up action authorized

                  Required when the request is not valid at this level. If not required by this implementation guide, do not send.

               6. 2500 · DMG · Dependent Demographic Information · Max 1 · Optional

                  To supply demographic information

                  Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.

               7. 2600 · INS · Dependent Relationship · Max 1 · Optional

                  To provide benefit information on insured entities

                  Required when used by the UMO to determine the benefit/level of service for this patient. If not required by this implementation guide, do not send.

            3. 2000E Loop Optional Repeat >1

               1. 0100 · HL · Patient Event Level · Max 1 · Mandatory

                  To identify dependencies among and the content of hierarchically related groups of data segments

                  Required when the UMO system processed any of the information contained in Loop 2000E of the request. If not required by this implementation guide, do not send.
                  If the UMO was unable to process any data beyond Loop 2000C or Loop 2000D of the request, this loop and any subordinate loops are not required.

               2. 0200 · TRN · Patient Event Tracking Number · Max 3 · Optional

                  To uniquely identify a transaction to an application

                  Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278 response.
                  If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.
                  If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
                  Required when this loop is returned and the request contained a tracking number at this level on the request, or when the UMO or clearinghouse assigns a trace number to this patient event in the response for tracking purposes. If not required by this implementation guide, do not send.

               3. 0300 · AAA · Patient Event Request Validation · Max 9 · Optional

                  To specify the validity of the request and indicate follow-up action authorized

                  Required when the request is not valid at this level. If not required by this implementation guide, do not send.
                  Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request.

               4. 0400 · UM · Health Care Services Review Information · Max 1 · Mandatory

                  To specify health care services review information

                  Identifies the type of health care services review.

               5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                  To specify the outcome of a health care services review

                  If the UMO for this service was unable to review the request due to missing or invalid application data at this level, the UMO must return a 278 response containing a AAA segment at this level.
                  If Loop 2000E is present in the response, either the AAA segment or the HCR segment must be returned in loop 2000E.
                  If the review outcome is pending additional medical information and the 278 response includes a request for additional information using either a PWK segment or an HI segment that specifies LOINC values, then the associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the appropriate health care services review decision reason code to indicate that additional information is required. Refer to Section 2.5 for more information.
                  Required when the UMO has reviewed the request at this level to provide patient event review outcome information or to indicate that the final decision is pending. If not required by this implementation guide, do not send.
                  If the response contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.

               6. 0600 · REF · Administrative Reference Number · Max 1 · Optional

                  To specify identifying information

                  Required when the HCR segment is valued in this loop, HCR01 = A3, A4 or CT and the UMO has assigned an administrative reference number associated with this service review. If not required by this implementation guide, do not send.
                  This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for reconsideration (UM02=6), to reference this UMO response.

               7. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                  To specify identifying information

                  Required when the certification number assigned by the UMO to the original service review outcome was used by the UMO to determine the outcome of this service review at the event level. If not required by this implementation guide, do not send.
                  This is the authorization number assigned by the UMO to the original review outcome associated with this event. This is not the trace number assigned by the requester.

               8. 0700 · DTP · Accident Date · Max 1 · Optional

                  To specify any or all of a date, a time, or a time period

                  Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
                  The total number of DTP segments in the 2000E loop cannot exceed 9.

               9. 0700 · DTP · Last Menstrual Period Date · Max 1 · Optional

                  To specify any or all of a date, a time, or a time period

                  Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
                  The total number of DTP segments in the 2000E loop cannot exceed 9.

               10. 0700 · DTP · Estimated Date of Birth · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               11. 0700 · DTP · Onset of Current Symptoms or Illness Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               12. 0700 · DTP · Event Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when the UMO authorizes service for a specific date or date range. If not required by this implementation guide, do not send.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               13. 0700 · DTP · Admission Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when the UMO authorizes admission for a specific date or date range. If not required by this implementation guide, do not send.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               14. 0700 · DTP · Discharge Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when the UMO authorizes services or admission based on the proposed or actual discharge date. If not required by this implementation guide, do not send.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               15. 0700 · DTP · Certification Issue Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when the UMO assigns a certification issue date to this authorization. If not required by this implementation guide, do not send.
                   This is not the effective date of the authorization. The issue date is that date when the UMO issued the authorization.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               16. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when the authorization has an expiration date to indicate the date on which the authorization will expire. If not required by this implementation guide, do not send.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               17. 0700 · DTP · Certification Effective Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when the authorization is limited by effective dates to indicate the date or date range when the authorization is effective. If not required by this implementation guide, do not send.
                   The total number of DTP segments in the 2000E loop cannot exceed 9.

               18. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                   To supply information related to the delivery of health care

                   If the response has not been rendered and this segment is used to request additional information associated with a specific diagnosis, place the specific diagnosis code in the HI C022 composite that precedes the HI C022 composite(s) containing the LOINC. If the original request contained more than six diagnosis codes and you are using LOINC to request additional information for each of these diagnosis codes or if you need to specify multiple questions/LOINC codes per diagnosis you cannot exceed the limit of 12 occurrences of the C022 composite.
                   Required when used by the UMO to render a medical decision or if the UMO is requesting additional information. If not required by this implementation guide, do not send.
                   The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes that identify the specific information that the UMO requires from the provider to complete the medical review. In the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical Observation Identifier Names and Codes (LOINC^®) List. These codes identify high-level health care information groupings, specific data elements, and associated modifiers. Refer to Section 1.12.5.2 of this guide for more information on requesting additional information in the 278 response.

               19. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                   To specify the delivery pattern of health care services

                   Required when the UMO authorizes services that have a specific pattern of delivery for the patient event. If not required by this implementation guide, do not send.
                   Report authorized delivery patterns for specific services in the Service Level (Loop 2000F).
                   An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".

               20. 1100 · CL1 · Institutional Claim Code · Max 1 · Optional

                   To supply information specific to hospital claims

                   Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

               21. 1200 · CR1 · Ambulance Transport Information · Max 1 · Optional

                   To supply information related to the ambulance service rendered to a patient

                   Use this segment for certifications involving non-emergency transport of the patient.
                   Required when used by the UMO to authorize specific non-emergency transport services. If not required by this implementation guide, do not send.

               22. 1300 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

                   To supply information related to the chiropractic service rendered to a patient

                   Required when used by the UMO to authorize spinal manipulation services that have a specific pattern of delivery usage. If not required by this implementation guide, do not send.

               23. 1400 · CR5 · Home Oxygen Therapy Information · Max 1 · Optional

                   To supply information regarding certification of medical necessity for home oxygen therapy

                   Required when used by the UMO to authorize specific usage of home oxygen therapy. If not required by this implementation guide, do not send.

               24. 1500 · CR6 · Home Health Care Information · Max 1 · Optional

                   To supply information related to the certification of a home health care patient

                   Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

               25. 1550 · PWK · Additional Patient Information · Max 10 · Optional

                   To identify the type or transmission or both of paperwork or supporting information

                   If the UMO has pended the decision on this health care services review request (HCR01 = A4) because additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the type of documentation needed such as forms that the provider must complete. The UMO can also indicate what medium it has used to send these forms.
                   Required when the UMO requests additional patient information. If not required by this implementation guide, do not send.
                   Paperwork requested at the patient level should apply to the patient event and/or all the services requested. Use the PWK segment in the appropriate Service loop if requesting medical necessity information for a specific service.
                   This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be referenced in the corresponding electronic attachment.
                   This PWK segment should not be used if a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid. b. the 278 request (ST-SE) does not support this information and the needed information pertains to a specific service identified in Loop 2000F and not to all the services requested. Refer to Section 2.5 for more information on using this segment.

               26. 1600 · MSG · Message Text · Max 1 · Optional

                   To provide a free-form format that allows the transmission of text information

                   Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.

               27. 2010EA Loop Optional Repeat 14

                   1. 1700 · NM1 · Patient Event Provider Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this patient event. If not required by this implementation guide, do not send.
                      Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.

                   2. 1800 · REF · Patient Event Provider Supplemental Identification · Max 7 · Optional

                      To specify identifying information

                      Required when used by the UMO to identify the Patient Event Provider. If not required by this implementation guide, do not send.
                      Use the NM1 segment for the primary identifier.

                   3. 2000 · N3 · Patient Event Provider Address · Max 1 · Optional

                      To specify the location of the named party

                      Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.

                   4. 2100 · N4 · Patient Event Provider City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.

                   5. 2200 · PER · Provider Contact Information · Max 1 · Optional

                      To identify a person or office to whom administrative communications should be directed

                      When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
                      By definition of the standard, if PER03 is used, PER04 is required.
                      Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                   6. 2300 · AAA · Patient Event Provider Request Validation · Max 9 · Optional

                      To specify the validity of the request and indicate follow-up action authorized

                      Required when the request is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.

                   7. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                      To specify the identifying characteristics of a provider

                      Required when used by the UMO to identify the provider. If not required by this implementation guide, do not send.

               28. 2010EB Loop Optional Repeat 1

                   1. 1700 · NM1 · Additional Patient Information Contact Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      Required when this Loop 2000E contains a request for additional information and the destination for that additional information differs from the UMO Name information in the NM1 loop (Loop 2010A) of the 278 response. If not required by this implementation guide, do not send.
                      Because the usage of this segment is "Situational" this is not a syntactically required loop. If this loop is used, then this segment is a "Required" segment. See Appendix A for further details on ASC X12;syntax rules. Refer to Section 2.5 for more information on this NM1 loop.

                   2. 2000 · N3 · Additional Patient Information Contact Address · Max 1 · Optional

                      To specify the location of the named party

                      This segment identifies the office location to route the response to the request for additional patient information.
                      Required when the response to the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                   3. 2100 · N4 · Additional Patient Information Contact City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when the response to the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                   4. 2200 · PER · Additional Patient Information Contact Information · Max 1 · Optional

                      To identify a person or office to whom administrative communications should be directed

                      When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
                      By definition of the standard, if PER03 is used, PER04 is required.
                      Required when the provider must direct the response to the request for additional patient information to a specific requester contact, electronic mail, facsimile, or phone number other than the contact provided in the PER segment in the UMO Name loop (Loop 2010A) PER segment of this 278 response. If not required by this implementation guide, do not send.

               29. 2010EC Loop Optional Repeat 5

                   1. 1700 · NM1 · Patient Event Transport Information · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      Required when used by the UMO to authorize specific transport services. If not required by this implementation guide, do not send.

                   2. 2000 · N3 · Patient Event Transport Location Address · Max 1 · Mandatory

                      To specify the location of the named party

                   3. 2100 · N4 · Patient Event Transport Location City/State/ZIP Code · Max 1 · Mandatory

                      To specify the geographic place of the named party

                   4. 2300 · AAA · Patient Event Transport Location Request Validation · Max 9 · Optional

                      To specify the validity of the request and indicate follow-up action authorized

                      Required when the request is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.

               30. 2000F Loop Optional Repeat >1

                   1. 0100 · HL · Service Level · Max 1 · Mandatory

                      To identify dependencies among and the content of hierarchically related groups of data segments

                      This segment identifies the service(s) requested and conveys the review outcome related to that service(s).
                      Required when the UMO system processed any of the information contained in Loop 2000F of the request. If not required by this implementation guide, do not send.
                      If the UMO was unable to process any data beyond Loop 2000C or Loop 2000D of the request, this loop and any subordinate loops are not required.

                   2. 0200 · TRN · Service Trace Number · Max 3 · Optional

                      To uniquely identify a transaction to an application

                      Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278 response.
                      If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.
                      If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
                      Required when this loop is returned and the request contained a tracking number at this level on the request, or when the UMO or clearinghouse assigns a trace number to this service in the response for tracking purposes. If not required by this implementation guide, do not send.

                   3. 0300 · AAA · Service Request Validation · Max 9 · Optional

                      To specify the validity of the request and indicate follow-up action authorized

                      If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
                      If Loop 2000F is present in the response, either the AAA segment or the HCR segment must be returned.
                      Required when the request is not valid at this level. If not required by this implementation guide, do not send.

                   4. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                      To specify health care services review information

                      Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

                   5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                      To specify the outcome of a health care services review

                      If the UMO for this service was unable to review the request due to missing or invalid application data at this level, the UMO must return a 278 response containing a AAA segment at this level.
                      If the review outcome is pending additional medical information and the 278 response includes a request for additional information using either a PWK segment or an HI segment that specifies LOINC values, then the associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the appropriate health care services review decision reason code to indicate that additional information is required. Refer to Section 2.5 for more information.
                      Required when the UMO has reviewed the request at this level, and the UMO renders a decision at both the Patient Event level and at the Service level, to provide service review outcome information and an associated reference number. If not required by this implementation guide, do not send.
                      If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.

                   6. 0600 · REF · Administrative Reference Number · Max 1 · Optional

                      To specify identifying information

                      Required when the HCR segment is valued in this loop and HCR01 = A3, A4 or CT, and the response does not carry an administrative reference number at the parent Patient Event level to assign an administrative reference number associated with this service line. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                      This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for reconsideration (UM02=6), to reference this UMO response.

                   7. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                      To specify identifying information

                      Required when the certification number assigned by the UMO to the original service review outcome associated with this service review was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.

                   8. 0700 · DTP · Service Date · Max 1 · Optional

                      To specify any or all of a date, a time, or a time period

                      Use this segment for the valid date(s) during which the service can be performed.
                      Required when the UMO authorizes service for a specific date or date range. If not required by this implementation guide, do not send.

                   9. 0700 · DTP · Certification Issue Date · Max 1 · Optional

                      To specify any or all of a date, a time, or a time period

                      Required when the UMO assigns a certification issue date to this authorization. If not required by this implementation guide, do not send.
                      This is not the effective date of the authorization. The issue date is that date when the UMO issued the authorization.

                   10. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

                       To specify any or all of a date, a time, or a time period

                       Required when the authorization has an expiration date to indicate the date on which the authorization will expire. If not required by this implementation guide, do not send.

                   11. 0700 · DTP · Certification Effective Date · Max 1 · Optional

                       To specify any or all of a date, a time, or a time period

                       Required when the authorization is limited by effective dates to indicate the date or date range when the authorization is effective. If not required by this implementation guide, do not send.

                   12. 0800 · HI · Request For Additional Information · Max 1 · Optional

                       To supply information related to the delivery of health care

                       The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes that identify the specific information that the UMO requires from the provider to complete the medical review. In the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical Observation Identifier Names and Codes (LOINC^®) List. These codes identify high-level health care information groupings, specific data elements, and associated modifiers. Refer to Section 1.12.5.2 of this guide for more information on requesting additional information.
                       Required when using LOINC to request additional information about this service. If not required by this implementation guide, do not send.

                   13. 0810 · SV1 · Professional Service · Max 1 · Optional

                       To specify the service line item detail for a health care professional

                       Required when authorizing a specific Professional Service. If not required by this implementation guide, do not send.

                   14. 0820 · SV2 · Institutional Service Line · Max 1 · Optional

                       To specify the service line item detail for a health care institution

                       Required when authorizing a specific Institutional Service. If not required by this implementation guide, do not send.
                       Use this segment to authorize a specific Revenue Code.

                   15. 0830 · SV3 · Dental Service · Max 1 · Optional

                       To specify the service line item detail for dental work

                       Required if authorizing a specific Dental Service. If not required by this implementation guide, do not send.
                       This segment is not used when the HI segment has been used to authorize a range of services in the same iteration of the 2000F loop.

                   16. 0840 · TOO · Tooth Information · Max 32 · Optional

                       To identify a tooth by number and, if applicable, one or more tooth surfaces

                       Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

                   17. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                       To specify the delivery pattern of health care services

                       Required when the UMO authorizes services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E or when identifying the number of medical services reservations remaining. If not required by this implementation guide, do not send.
                       An explanation of the uses of this segment or delivery pattern is as follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
                       An explanation of the use of this segment for identifying the number of medical service reservations remaining is as follows: HSD05 qualifies HSD06. If the value in HSD06=5 and the value in HSD05=29, this means there are 5 service reservations remaining.

                   18. 1550 · PWK · Additional Service Information · Max 10 · Optional

                       To identify the type or transmission or both of paperwork or supporting information

                       If the UMO has pended the decision on this health care services review request (HCR01 = A4) because additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the type of documentation needed such as forms that the provider must complete. The UMO can also indicate what medium it has used to send these forms.
                       Required when the UMO needs to request additional information that applies to the service(s) requested in this Service loop. If not required by this implementation guide, do not send.
                       Additional information requested at the Service level should apply to a specific service and/or all the services requested in this service loop.
                       This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be referenced in the corresponding electronic attachment.
                       This PWK segment should not be used if a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid. b. the 278 request (ST-SE) does not support this information and the needed information pertains to all the services requested and not to a specific service. Use the PWK segment at the Patient Event level (Loop 2000E) if requesting medical necessity information that applies to all the services requested. Refer to Section 2.5 for more information on using this segment.

                   19. 1600 · MSG · Message Text · Max 1 · Optional

                       To provide a free-form format that allows the transmission of text information

                       Required when it is necessary to send additional information about the Service which could not otherwise be codified within the 2000F Loop. If not required by this implementation guide, do not send.

                   20. 2010FA Loop Optional Repeat 12

                       1. 1700 · NM1 · Service Provider Name · Max 1 · Mandatory

                          To supply the full name of an individual or organizational entity

                          Use this segment to convey the name and identification number of the service provider (person, group, or facility) or to identify the specialty entity.
                          Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this service. If not required by this implementation guide, do not send.

                       2. 1800 · REF · Service Provider Supplemental Identification · Max 8 · Optional

                          To specify identifying information

                          Required when used by the UMO to identify the Service Provider. If not required by this implementation guide, do not send.
                          Use the NM1 segment for the primary identifier.

                       3. 2000 · N3 · Service Provider Address · Max 1 · Optional

                          To specify the location of the named party

                          Required when the UMO authorizes a specific location for a service provider that has multiple locations. If not required by this implementation guide, do not send.

                       4. 2100 · N4 · Service Provider City, State, ZIP Code · Max 1 · Optional

                          To specify the geographic place of the named party

                          Required when the UMO authorizes a specific location for a service provider that has multiple locations. If not required by this implementation guide, do not send.

                       5. 2200 · PER · Service Provider Contact Information · Max 1 · Optional

                          To identify a person or office to whom administrative communications should be directed

                          When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
                          Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                       6. 2300 · AAA · Service Provider Request Validation · Max 9 · Optional

                          To specify the validity of the request and indicate follow-up action authorized

                          Required when the request is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.

                       7. 2400 · PRV · Service Provider Information · Max 1 · Optional

                          To specify the identifying characteristics of a provider

                          Required when used by the UMO to identify the provider. If not required by this implementation guide, do not send.

                   21. 2010FB Loop Optional Repeat 1

                       1. 1700 · NM1 · Additional Service Information Contact Name · Max 1 · Mandatory

                          To supply the full name of an individual or organizational entity

                          Because the usage of this segment is "Situational" this is not a syntactically required loop. If this loop is used, then this segment is a "Required" segment. See Appendix A for further details on ASC X12;syntax rules. Refer to Section 2.5 for more information on this NM1 loop.
                          Required when Loop 2000F contains a request for additional information and the destination for that additional information differs from the UMO Name information in the NM1 loop (Loop 2010A) of the 278 response. If not required by this implementation guide, do not send.

                       2. 2000 · N3 · Additional Service Information Contact Address · Max 1 · Optional

                          To specify the location of the named party

                          Required when the response to the request for additional service information must be routed to a specific office location. If not required by this implementation guide, do not send.
                          This segment identifies the office location to route the response to the request for additional service information.

                       3. 2100 · N4 · Additional Service Information Contact City, State, ZIP Code · Max 1 · Optional

                          To specify the geographic place of the named party

                          Required when the response to the request for additional service information must be routed to a specific office location. If not required by this implementation guide, do not send.

                       4. 2200 · PER · Additional Service Information Contact Information · Max 1 · Optional

                          To identify a person or office to whom administrative communications should be directed

                          Do not use if the request for additional service information is in another X12 functional group.
                          Required when the provider must direct the response to the request for additional service information to a specific requester contact, electronic mail, facsimile, or phone number other than the contact provided in the PER segment in the UMO Name loop (Loop 2010A) PER segment of this 278 response. If not required by this implementation guide, do not send.
                          When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.

         4. 2000E Loop Optional Repeat >1

            1. 0100 · HL · Patient Event Level · Max 1 · Mandatory

               To identify dependencies among and the content of hierarchically related groups of data segments

               Required when the UMO system processed any of the information contained in Loop 2000E of the request. If not required by this implementation guide, do not send.
               If the UMO was unable to process any data beyond Loop 2000C or Loop 2000D of the request, this loop and any subordinate loops are not required.

            2. 0200 · TRN · Patient Event Tracking Number · Max 3 · Optional

               To uniquely identify a transaction to an application

               Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278 response.
               If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.
               If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
               Required when this loop is returned and the request contained a tracking number at this level on the request, or when the UMO or clearinghouse assigns a trace number to this patient event in the response for tracking purposes. If not required by this implementation guide, do not send.

            3. 0300 · AAA · Patient Event Request Validation · Max 9 · Optional

               To specify the validity of the request and indicate follow-up action authorized

               Required when the request is not valid at this level. If not required by this implementation guide, do not send.
               Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request.

            4. 0400 · UM · Health Care Services Review Information · Max 1 · Mandatory

               To specify health care services review information

               Identifies the type of health care services review.

            5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

               To specify the outcome of a health care services review

               If the UMO for this service was unable to review the request due to missing or invalid application data at this level, the UMO must return a 278 response containing a AAA segment at this level.
               If Loop 2000E is present in the response, either the AAA segment or the HCR segment must be returned in loop 2000E.
               If the review outcome is pending additional medical information and the 278 response includes a request for additional information using either a PWK segment or an HI segment that specifies LOINC values, then the associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the appropriate health care services review decision reason code to indicate that additional information is required. Refer to Section 2.5 for more information.
               Required when the UMO has reviewed the request at this level to provide patient event review outcome information or to indicate that the final decision is pending. If not required by this implementation guide, do not send.
               If the response contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.

            6. 0600 · REF · Administrative Reference Number · Max 1 · Optional

               To specify identifying information

               Required when the HCR segment is valued in this loop, HCR01 = A3, A4 or CT and the UMO has assigned an administrative reference number associated with this service review. If not required by this implementation guide, do not send.
               This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for reconsideration (UM02=6), to reference this UMO response.

            7. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

               To specify identifying information

               Required when the certification number assigned by the UMO to the original service review outcome was used by the UMO to determine the outcome of this service review at the event level. If not required by this implementation guide, do not send.
               This is the authorization number assigned by the UMO to the original review outcome associated with this event. This is not the trace number assigned by the requester.

            8. 0700 · DTP · Accident Date · Max 1 · Optional

               To specify any or all of a date, a time, or a time period

               Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
               The total number of DTP segments in the 2000E loop cannot exceed 9.

            9. 0700 · DTP · Last Menstrual Period Date · Max 1 · Optional

               To specify any or all of a date, a time, or a time period

               Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
               The total number of DTP segments in the 2000E loop cannot exceed 9.

            10. 0700 · DTP · Estimated Date of Birth · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            11. 0700 · DTP · Onset of Current Symptoms or Illness Date · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            12. 0700 · DTP · Event Date · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when the UMO authorizes service for a specific date or date range. If not required by this implementation guide, do not send.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            13. 0700 · DTP · Admission Date · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when the UMO authorizes admission for a specific date or date range. If not required by this implementation guide, do not send.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            14. 0700 · DTP · Discharge Date · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when the UMO authorizes services or admission based on the proposed or actual discharge date. If not required by this implementation guide, do not send.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            15. 0700 · DTP · Certification Issue Date · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when the UMO assigns a certification issue date to this authorization. If not required by this implementation guide, do not send.
                This is not the effective date of the authorization. The issue date is that date when the UMO issued the authorization.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            16. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when the authorization has an expiration date to indicate the date on which the authorization will expire. If not required by this implementation guide, do not send.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            17. 0700 · DTP · Certification Effective Date · Max 1 · Optional

                To specify any or all of a date, a time, or a time period

                Required when the authorization is limited by effective dates to indicate the date or date range when the authorization is effective. If not required by this implementation guide, do not send.
                The total number of DTP segments in the 2000E loop cannot exceed 9.

            18. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                To supply information related to the delivery of health care

                If the response has not been rendered and this segment is used to request additional information associated with a specific diagnosis, place the specific diagnosis code in the HI C022 composite that precedes the HI C022 composite(s) containing the LOINC. If the original request contained more than six diagnosis codes and you are using LOINC to request additional information for each of these diagnosis codes or if you need to specify multiple questions/LOINC codes per diagnosis you cannot exceed the limit of 12 occurrences of the C022 composite.
                Required when used by the UMO to render a medical decision or if the UMO is requesting additional information. If not required by this implementation guide, do not send.
                The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes that identify the specific information that the UMO requires from the provider to complete the medical review. In the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical Observation Identifier Names and Codes (LOINC^®) List. These codes identify high-level health care information groupings, specific data elements, and associated modifiers. Refer to Section 1.12.5.2 of this guide for more information on requesting additional information in the 278 response.

            19. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                To specify the delivery pattern of health care services

                Required when the UMO authorizes services that have a specific pattern of delivery for the patient event. If not required by this implementation guide, do not send.
                Report authorized delivery patterns for specific services in the Service Level (Loop 2000F).
                An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".

            20. 1100 · CL1 · Institutional Claim Code · Max 1 · Optional

                To supply information specific to hospital claims

                Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

            21. 1200 · CR1 · Ambulance Transport Information · Max 1 · Optional

                To supply information related to the ambulance service rendered to a patient

                Use this segment for certifications involving non-emergency transport of the patient.
                Required when used by the UMO to authorize specific non-emergency transport services. If not required by this implementation guide, do not send.

            22. 1300 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

                To supply information related to the chiropractic service rendered to a patient

                Required when used by the UMO to authorize spinal manipulation services that have a specific pattern of delivery usage. If not required by this implementation guide, do not send.

            23. 1400 · CR5 · Home Oxygen Therapy Information · Max 1 · Optional

                To supply information regarding certification of medical necessity for home oxygen therapy

                Required when used by the UMO to authorize specific usage of home oxygen therapy. If not required by this implementation guide, do not send.

            24. 1500 · CR6 · Home Health Care Information · Max 1 · Optional

                To supply information related to the certification of a home health care patient

                Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

            25. 1550 · PWK · Additional Patient Information · Max 10 · Optional

                To identify the type or transmission or both of paperwork or supporting information

                If the UMO has pended the decision on this health care services review request (HCR01 = A4) because additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the type of documentation needed such as forms that the provider must complete. The UMO can also indicate what medium it has used to send these forms.
                Required when the UMO requests additional patient information. If not required by this implementation guide, do not send.
                Paperwork requested at the patient level should apply to the patient event and/or all the services requested. Use the PWK segment in the appropriate Service loop if requesting medical necessity information for a specific service.
                This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be referenced in the corresponding electronic attachment.
                This PWK segment should not be used if a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid. b. the 278 request (ST-SE) does not support this information and the needed information pertains to a specific service identified in Loop 2000F and not to all the services requested. Refer to Section 2.5 for more information on using this segment.

            26. 1600 · MSG · Message Text · Max 1 · Optional

                To provide a free-form format that allows the transmission of text information

                Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.

            27. 2010EA Loop Optional Repeat 14

                1. 1700 · NM1 · Patient Event Provider Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this patient event. If not required by this implementation guide, do not send.
                   Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.

                2. 1800 · REF · Patient Event Provider Supplemental Identification · Max 7 · Optional

                   To specify identifying information

                   Required when used by the UMO to identify the Patient Event Provider. If not required by this implementation guide, do not send.
                   Use the NM1 segment for the primary identifier.

                3. 2000 · N3 · Patient Event Provider Address · Max 1 · Optional

                   To specify the location of the named party

                   Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.

                4. 2100 · N4 · Patient Event Provider City, State, ZIP Code · Max 1 · Optional

                   To specify the geographic place of the named party

                   Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.

                5. 2200 · PER · Provider Contact Information · Max 1 · Optional

                   To identify a person or office to whom administrative communications should be directed

                   When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
                   By definition of the standard, if PER03 is used, PER04 is required.
                   Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                6. 2300 · AAA · Patient Event Provider Request Validation · Max 9 · Optional

                   To specify the validity of the request and indicate follow-up action authorized

                   Required when the request is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.

                7. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                   To specify the identifying characteristics of a provider

                   Required when used by the UMO to identify the provider. If not required by this implementation guide, do not send.

            28. 2010EB Loop Optional Repeat 1

                1. 1700 · NM1 · Additional Patient Information Contact Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when this Loop 2000E contains a request for additional information and the destination for that additional information differs from the UMO Name information in the NM1 loop (Loop 2010A) of the 278 response. If not required by this implementation guide, do not send.
                   Because the usage of this segment is "Situational" this is not a syntactically required loop. If this loop is used, then this segment is a "Required" segment. See Appendix A for further details on ASC X12;syntax rules. Refer to Section 2.5 for more information on this NM1 loop.

                2. 2000 · N3 · Additional Patient Information Contact Address · Max 1 · Optional

                   To specify the location of the named party

                   This segment identifies the office location to route the response to the request for additional patient information.
                   Required when the response to the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                3. 2100 · N4 · Additional Patient Information Contact City, State, ZIP Code · Max 1 · Optional

                   To specify the geographic place of the named party

                   Required when the response to the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                4. 2200 · PER · Additional Patient Information Contact Information · Max 1 · Optional

                   To identify a person or office to whom administrative communications should be directed

                   When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
                   By definition of the standard, if PER03 is used, PER04 is required.
                   Required when the provider must direct the response to the request for additional patient information to a specific requester contact, electronic mail, facsimile, or phone number other than the contact provided in the PER segment in the UMO Name loop (Loop 2010A) PER segment of this 278 response. If not required by this implementation guide, do not send.

            29. 2010EC Loop Optional Repeat 5

                1. 1700 · NM1 · Patient Event Transport Information · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when used by the UMO to authorize specific transport services. If not required by this implementation guide, do not send.

                2. 2000 · N3 · Patient Event Transport Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                3. 2100 · N4 · Patient Event Transport Location City/State/ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

                4. 2300 · AAA · Patient Event Transport Location Request Validation · Max 9 · Optional

                   To specify the validity of the request and indicate follow-up action authorized

                   Required when the request is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.

            30. 2000F Loop Optional Repeat >1

                1. 0100 · HL · Service Level · Max 1 · Mandatory

                   To identify dependencies among and the content of hierarchically related groups of data segments

                   This segment identifies the service(s) requested and conveys the review outcome related to that service(s).
                   Required when the UMO system processed any of the information contained in Loop 2000F of the request. If not required by this implementation guide, do not send.
                   If the UMO was unable to process any data beyond Loop 2000C or Loop 2000D of the request, this loop and any subordinate loops are not required.

                2. 0200 · TRN · Service Trace Number · Max 3 · Optional

                   To uniquely identify a transaction to an application

                   Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278 response.
                   If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.
                   If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
                   Required when this loop is returned and the request contained a tracking number at this level on the request, or when the UMO or clearinghouse assigns a trace number to this service in the response for tracking purposes. If not required by this implementation guide, do not send.

                3. 0300 · AAA · Service Request Validation · Max 9 · Optional

                   To specify the validity of the request and indicate follow-up action authorized

                   If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
                   If Loop 2000F is present in the response, either the AAA segment or the HCR segment must be returned.
                   Required when the request is not valid at this level. If not required by this implementation guide, do not send.

                4. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                   To specify health care services review information

                   Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

                5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                   To specify the outcome of a health care services review

                   If the UMO for this service was unable to review the request due to missing or invalid application data at this level, the UMO must return a 278 response containing a AAA segment at this level.
                   If the review outcome is pending additional medical information and the 278 response includes a request for additional information using either a PWK segment or an HI segment that specifies LOINC values, then the associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the appropriate health care services review decision reason code to indicate that additional information is required. Refer to Section 2.5 for more information.
                   Required when the UMO has reviewed the request at this level, and the UMO renders a decision at both the Patient Event level and at the Service level, to provide service review outcome information and an associated reference number. If not required by this implementation guide, do not send.
                   If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.

                6. 0600 · REF · Administrative Reference Number · Max 1 · Optional

                   To specify identifying information

                   Required when the HCR segment is valued in this loop and HCR01 = A3, A4 or CT, and the response does not carry an administrative reference number at the parent Patient Event level to assign an administrative reference number associated with this service line. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                   This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for reconsideration (UM02=6), to reference this UMO response.

                7. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                   To specify identifying information

                   Required when the certification number assigned by the UMO to the original service review outcome associated with this service review was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.

                8. 0700 · DTP · Service Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Use this segment for the valid date(s) during which the service can be performed.
                   Required when the UMO authorizes service for a specific date or date range. If not required by this implementation guide, do not send.

                9. 0700 · DTP · Certification Issue Date · Max 1 · Optional

                   To specify any or all of a date, a time, or a time period

                   Required when the UMO assigns a certification issue date to this authorization. If not required by this implementation guide, do not send.
                   This is not the effective date of the authorization. The issue date is that date when the UMO issued the authorization.

                10. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

                    To specify any or all of a date, a time, or a time period

                    Required when the authorization has an expiration date to indicate the date on which the authorization will expire. If not required by this implementation guide, do not send.

                11. 0700 · DTP · Certification Effective Date · Max 1 · Optional

                    To specify any or all of a date, a time, or a time period

                    Required when the authorization is limited by effective dates to indicate the date or date range when the authorization is effective. If not required by this implementation guide, do not send.

                12. 0800 · HI · Request For Additional Information · Max 1 · Optional

                    To supply information related to the delivery of health care

                    The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes that identify the specific information that the UMO requires from the provider to complete the medical review. In the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical Observation Identifier Names and Codes (LOINC^®) List. These codes identify high-level health care information groupings, specific data elements, and associated modifiers. Refer to Section 1.12.5.2 of this guide for more information on requesting additional information.
                    Required when using LOINC to request additional information about this service. If not required by this implementation guide, do not send.

                13. 0810 · SV1 · Professional Service · Max 1 · Optional

                    To specify the service line item detail for a health care professional

                    Required when authorizing a specific Professional Service. If not required by this implementation guide, do not send.

                14. 0820 · SV2 · Institutional Service Line · Max 1 · Optional

                    To specify the service line item detail for a health care institution

                    Required when authorizing a specific Institutional Service. If not required by this implementation guide, do not send.
                    Use this segment to authorize a specific Revenue Code.

                15. 0830 · SV3 · Dental Service · Max 1 · Optional

                    To specify the service line item detail for dental work

                    Required if authorizing a specific Dental Service. If not required by this implementation guide, do not send.
                    This segment is not used when the HI segment has been used to authorize a range of services in the same iteration of the 2000F loop.

                16. 0840 · TOO · Tooth Information · Max 32 · Optional

                    To identify a tooth by number and, if applicable, one or more tooth surfaces

                    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

                17. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                    To specify the delivery pattern of health care services

                    Required when the UMO authorizes services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E or when identifying the number of medical services reservations remaining. If not required by this implementation guide, do not send.
                    An explanation of the uses of this segment or delivery pattern is as follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
                    An explanation of the use of this segment for identifying the number of medical service reservations remaining is as follows: HSD05 qualifies HSD06. If the value in HSD06=5 and the value in HSD05=29, this means there are 5 service reservations remaining.

                18. 1550 · PWK · Additional Service Information · Max 10 · Optional

                    To identify the type or transmission or both of paperwork or supporting information

                    If the UMO has pended the decision on this health care services review request (HCR01 = A4) because additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the type of documentation needed such as forms that the provider must complete. The UMO can also indicate what medium it has used to send these forms.
                    Required when the UMO needs to request additional information that applies to the service(s) requested in this Service loop. If not required by this implementation guide, do not send.
                    Additional information requested at the Service level should apply to a specific service and/or all the services requested in this service loop.
                    This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be referenced in the corresponding electronic attachment.
                    This PWK segment should not be used if a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid. b. the 278 request (ST-SE) does not support this information and the needed information pertains to all the services requested and not to a specific service. Use the PWK segment at the Patient Event level (Loop 2000E) if requesting medical necessity information that applies to all the services requested. Refer to Section 2.5 for more information on using this segment.

                19. 1600 · MSG · Message Text · Max 1 · Optional

                    To provide a free-form format that allows the transmission of text information

                    Required when it is necessary to send additional information about the Service which could not otherwise be codified within the 2000F Loop. If not required by this implementation guide, do not send.

                20. 2010FA Loop Optional Repeat 12

                    1. 1700 · NM1 · Service Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Use this segment to convey the name and identification number of the service provider (person, group, or facility) or to identify the specialty entity.
                       Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this service. If not required by this implementation guide, do not send.

                    2. 1800 · REF · Service Provider Supplemental Identification · Max 8 · Optional

                       To specify identifying information

                       Required when used by the UMO to identify the Service Provider. If not required by this implementation guide, do not send.
                       Use the NM1 segment for the primary identifier.

                    3. 2000 · N3 · Service Provider Address · Max 1 · Optional

                       To specify the location of the named party

                       Required when the UMO authorizes a specific location for a service provider that has multiple locations. If not required by this implementation guide, do not send.

                    4. 2100 · N4 · Service Provider City, State, ZIP Code · Max 1 · Optional

                       To specify the geographic place of the named party

                       Required when the UMO authorizes a specific location for a service provider that has multiple locations. If not required by this implementation guide, do not send.

                    5. 2200 · PER · Service Provider Contact Information · Max 1 · Optional

                       To identify a person or office to whom administrative communications should be directed

                       When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
                       Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                    6. 2300 · AAA · Service Provider Request Validation · Max 9 · Optional

                       To specify the validity of the request and indicate follow-up action authorized

                       Required when the request is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.

                    7. 2400 · PRV · Service Provider Information · Max 1 · Optional

                       To specify the identifying characteristics of a provider

                       Required when used by the UMO to identify the provider. If not required by this implementation guide, do not send.

                21. 2010FB Loop Optional Repeat 1

                    1. 1700 · NM1 · Additional Service Information Contact Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Because the usage of this segment is "Situational" this is not a syntactically required loop. If this loop is used, then this segment is a "Required" segment. See Appendix A for further details on ASC X12;syntax rules. Refer to Section 2.5 for more information on this NM1 loop.
                       Required when Loop 2000F contains a request for additional information and the destination for that additional information differs from the UMO Name information in the NM1 loop (Loop 2010A) of the 278 response. If not required by this implementation guide, do not send.

                    2. 2000 · N3 · Additional Service Information Contact Address · Max 1 · Optional

                       To specify the location of the named party

                       Required when the response to the request for additional service information must be routed to a specific office location. If not required by this implementation guide, do not send.
                       This segment identifies the office location to route the response to the request for additional service information.

                    3. 2100 · N4 · Additional Service Information Contact City, State, ZIP Code · Max 1 · Optional

                       To specify the geographic place of the named party

                       Required when the response to the request for additional service information must be routed to a specific office location. If not required by this implementation guide, do not send.

                    4. 2200 · PER · Additional Service Information Contact Information · Max 1 · Optional

                       To identify a person or office to whom administrative communications should be directed

                       Do not use if the request for additional service information is in another X12 functional group.
                       Required when the provider must direct the response to the request for additional service information to a specific requester contact, electronic mail, facsimile, or phone number other than the contact provided in the PER segment in the UMO Name loop (Loop 2010A) PER segment of this 278 response. If not required by this implementation guide, do not send.
                       When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.

2. 2800 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)